Name: satli Home Phone:

087898765432

Address: sumenep Office Phone:

Patient ID: 2018098 Fax:

Birth Date: 02/02/1997 Status: Active

Gender: Male Marital Status:

Married

Contact By: Phone Race: White

Problems

DIABETES MELLITUS (ICD-250.)

Medications

PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd

Last Refill: #30 x 2 : Carl Savem MD (11/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0: Carl Savem MD (11/27/2010)

Directives

Allergies and Adverse Reactions (! = critical)

Services Due

CREATININE

2/1/2018 - Office Visit: F/u Diabetes

Provider: Carl Savem MD
Location of Care: WeServeEveryone Clinic

OFFICE VISIT

History of Present Illness

Reason for visit: Routine follow up to review medications
Chief Complaint: No complaints
History

Diabetes Management
Hyperglycemic Symptoms
Polyuria: no
Polydipsia: no
Blurred vision: no

Sympathomimetic Symptoms
Diaphoresis: no
Agitation: no
Tremor: no
Palpitations: no
Insomnia: no

Neuroglycopenic Symptoms
Confusion: no
Lethargy: no
Somnolence: no
Amnesia: no
Stupor: no
Seizures: no

Review of Systems

General: denies fatigue, malaise, fever, weight loss

Eyes: denies blurring, diplopia, irritation, discharge
Ear/Nose/Throat: denies ear pain or discharge, nasal obstruction or discharge, sore throat
Cardiovascular: denies chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea,
edema Respiratory: denies coughing, wheezing, dyspnea, hemoptysis
Gastrointestinal: denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, constipation
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge, impotence,
incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: denies rashes, itching, lumps, sores, lesions, color change
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: denies depression, anxiety, mental disturbance, difficulty sleeping, suicidal
ideation, hallucinations, paranoia
Endocrine: denies polyuria, polydipsia, polyphagia, weight change, heat or cold intolerance
Heme/Lymphatic: denies easy or excessive bruising, history of blood transfusions, anemia,
bleeding disorders, adenopathy, chills, sweats
Allergic/Immunologic: denies urticaria, hay fever, frequent UTIs; denies HIV high risk
behaviors

Vital Signs
Ht: 71 in. Wt: 191 lbs. T: 98.0 degF. T site: oral P: 70 Rhythm: regular R: 16 BP: 118/70

Physical Exam

General Appearance: no acute distress

Eyes: conjunctiva and lids normal, PERRLA, EOMI, fundi WNL
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: clear to auscultation and percussion, respiratory effort normal
Cardiovascular: regular rate and rhythm, S1-S2, no murmur, rub or gallop, no bruits, peripheral
pulses normal and symmetric, no cyanosis, clubbing, edema or varicosities
Skin: clear, good turgor, color WNL, no rashes, lesions, or ulcerations

Assessment

Problems (including changes): Feet are inspected and there are no callouses, no compromised
skin. No vision complaints.

Impression: Sub optimal sugar, control with retinopathy and neuropathy, high glucometer
readings.

Plan

Medications:
HUMULIN INJ 70/30 20 u ac breakfast

PRINIVIL TABS 20 MG 1 qd

Treatment: Will have annual foot exam at next visit.

Orders:

Lipid Panel

Education/Counseling (time): 15 minutes

Coordination of Care (time): 5 minutes

Follow-up/Return Visit: 3 months

Disposition: return to clinic

Tests:

(1) Metabolic Panel (ML-03CHEM)

ALK PHOS 72 U/L 35-100

BG RANDOM 125 mg/dl 70-125

BUN 16 mg/dl 7-25

CALCIUM 9.6 mg/dl 8.2-10.2

CHLORIDE 101 mmol/l 96-109

CO2 27 mmol/l 23-29

CREATININE 0.7 mg/dl 0.6-1.2

PO4 2.9 mg/dl 2.5-4.5

POTASSIUM 4.5 mmol/l 3.5-5.3

SGOT (AST) 31 U/L 0-40

BILI TOTAL 0.7 mg/dl 0.0-1.3

URIC ACID 4.8 mg/dl 3.4-7.0

LDH, TOTAL 136 IU/L 0-200

SODIUM 135 mmol/l 135-145

(2) HbA1c Test

HbA1c level 5.0%
(3) Lipid Profile
Cholesterol, Total 210 mg/dl
Triglycerides 236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 87

WeServeEveryone Clinic March 24, 2011

1111 First Street California Page 2

111-111-11111 Fax: 111-111-1111 Chart Summary

Steve Apple

Male DOB: 02/02/1945 Home: 222-222-2222

0000-22222
Ins: Commercial xxxxx
Flowsheet

Date 12/18/2010

HEIGHT (in) 71

WEIGHT (lb) 191

TEMPERATURE (deg F) 98

TEMP SITE oral

PULSE RATE (/min) 72

PULSE RHYTHM

RESP RATE (/min) 16

BP SYSTOLIC (mm Hg) 118

BP DIASTOLIC (mm Hg) 70

CHOLESTEROL (mg/dL)

HDL (mg/dL) 87

LDL (mg/dL) 125

BG RANDOM (mg/dL)

CXR

EKG

PAP SMEAR

BREAST EXAM

MAMMOGRAM

HEMOCCULT neg

FLU VAX 0.5 ml g

PNEUMOVAX 0.5 ml g

TD BOOSTER 0.5 ml g

Foot Exam Complete

Eye Exam Complete